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Atrial Fibrillation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REASON FOR CONSULTATION:  Atrial fibrillation.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with no known history of organic heart disease, who was found to be in atrial fibrillation on a routine examination.  The patient denies any history of tachypalpitations.  She denies any recent history of increased fatigue or shortness of breath.  The patient denies PND, orthopnea, pedal edema or exertional chest discomfort.

PAST MEDICAL AND SURGICAL HISTORY:
1.  Ectopic pregnancy.
2.  Ventral hernia.

CORONARY DISEASE RISK FACTORS:
1.  Cigarettes are positive.  The patient smokes about a pack a week, but at her peak was smoking three packs a day.
2.  Diabetes is negative.
3.  Hypertension is negative.
4.  Cholesterol was 155, HDL 30, LDL 108, and triglycerides are 78.

SOCIAL HISTORY:  The patient is not a drinker.  The patient does not get much exercise.

FAMILY HISTORY:  Negative for premature coronary disease.

ALLERGIES:  No known allergies.

MEDICATIONS:
1.  Metoprolol 50 mg daily.
2.  Aspirin 5 grains daily.
3.  Citracal 250 mg daily.
4.  Multivitamin daily.
5.  Actonel 35 mg once a week.

REVIEW OF SYSTEMS:
GENERAL:  Weight is down 5 to 10 pounds.  She denies any fever or chills.
CARDIORESPIRATORY:  As in the present illness.
NEUROLOGIC:  She denies any symptoms compatible with TIAs.
MUSCULOSKELETAL:  There are no symptoms of intermittent claudication.
GENITOURINARY:  There is no hematuria or dysuria.
GASTROINTESTINAL:  There is no hematochezia or melena.
SKIN:  There are no new rashes.
HEMATOLOGIC:  She does not bruise easily.
The rest of review of systems is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Blood pressure 124/64, heart rate of 114 and irregularly irregular.
GENERAL:  The patient is a well-developed and well-nourished female, in no acute distress.  She is alert, oriented, and cooperative with normal affect.
HEENT:  Head is negative.  Eyes:  EOMs are intact.  Sclerae white.  Conjunctivae are pink.  The mouth is without lesions.  The tongue protrudes in the midline.
NECK:  Without JVD.  Carotid pulses are 2+ and equal.  There are no bruits.
LUNGS:  Clear except for bilateral scattered rhonchi.
HEART:  Irregularly irregular rhythm.  There is a soft 2/6 apical systolic murmur.  There is no S3.  There is no diastolic murmur appreciated.
ABDOMEN:  Soft and nontender.  No palpable masses or organomegaly.  The abdominal aorta was not palpable.  Bowel sounds were active.  There was no abdominal bruit appreciated.
EXTREMITIES:  Without edema bilaterally.  Femoral pulses are 2+ and equal without bruits.  Dorsalis pedis pulses 2+ on the left, not palpable on the right.  Posterior tibial was not palpable on the right and 1+ on the left.
NEUROLOGIC:  Grossly intact.

LABORATORY DATA:  CBC showed hemoglobin, hematocrit, white count, and platelet counts to be normal.  Free T4 is 1.4, which is within normal limits.  Electrolytes: BUN and creatinine are normal.

IMPRESSION:
1.  Atrial fibrillation of undetermined age.  The patient is basically asymptomatic with this.  Rates, however, are somewhat fast.
2.  The patient may have peripheral vascular disease, but it is asymptomatic.

RECOMMENDATIONS:
1.  We are going to go ahead and increase the metoprolol to 75 mg b.i.d.
2.  We will anticoagulate her with Lovenox and Coumadin.
3.  We will set her up for an adenosine Cardiolite stress test.
4.  We spoke about the importance of her stopping her cigarettes completely.

Thank you, Dr. John Doe, for asking us to see the patient.

Cardiology Consult Sample Report